ALL Fundamentals of Care

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for a potassium deficit?

The client receiving nasogastric suction Rationale:Potassium-rich gastrointestinal (GI) fluids are lost through GI suction, which places the client at risk for hypokalemia. The client with intestinal obstruction, Addison's disease, and metabolic acidosis is at risk for hyperkalemia.

The nursing instructor asks the student to describe isotonic dehydration. The student correctly responds by stating which pathophysiological processes are occurring? Select all that apply.

"Water and electrolytes are lost in approximately the same proportion as they exist in the body." "A client who has a large blood loss due to an accident will initially have an isotonic dehydration." Rationale:Isotonic dehydration occurs when water and electrolytes are lost in approximately the same proportion as they exist in the body. In this type of dehydration, the serum sodium levels remain normal (135 to 145 mEq/L [135 to 145 mmol/L]). A client who loses a large amount of blood initially is dehydrated, but the electrolytes are lost proportionately. "The loss of electrolytes is greater than the loss of water." and "The client is likely to have impaired mental status due to low sodium levels."describe hypotonic dehydration in which the serum sodium level is less than 130 mEq/L (130 mmol/L). "The loss of water is greater than the loss of electrolytes." and "Serum sodium level rises above 150 mEq/L (150 mmol/L)." describe hypertonic dehydration.

Which is the most appropriate catheter for a male client with severe urinary retention, a history of urinary tract infections, and a stage 4 pressure injury on the coccyx? Refer to chart.

3 Rationale:Long-term indwelling catheters are used with severe urinary retention, recurrent urinary tract infections, and when wounds are irritated by contact with urine. Silicon is preferred because it can stay in place for 2 to 3 months. Size 14 to 16 are standard sizes, and only sterile water should be used to inflate the balloon. Saline will crystallize in the balloon. Intermittent and short-term catheterization would not solve the issue of severe urinary retention and would require repeated catheterization, increasing risk of infection. A condom catheter will not remedy urinary retention and does not have a balloon.

The nurse is obtaining the report for a group of assigned clients. The nurse plans to monitor the serum potassium levels in which clients at risk for hyperkalemia? Select all that apply.

A client with a new burn injury A client diagnosed with acute kidney injury (AKI) Rationale:Hyperkalemia is likely to occur in clients who experience cellular shifting of potassium (from intracellular to extracellular) from early massive cell destruction such as in trauma or burns. Clients with altered kidney function, such as those with AKI, are at risk because the normally functioning kidney excretes potassium. Other clients at risk for hyperkalemia are those with sepsis or metabolic or respiratory acidosis. Clients with Cushing's syndrome or ulcerative colitis or those using laxatives excessively are at risk for hypokalemia.

The nurse is caring for a group of clients on a clinical nursing unit. The nurse checks for signs of deficient fluid volume. Which clients are at risk for this fluid imbalance? Select all that apply.

A client with pneumonia A client with an ileostomy A client with a temperature of 102.5° F (39.2° C) Rationale:The client with an ileostomy is at risk for deficient fluid volume because of increased gastrointestinal tract losses. The client with pneumonia is at risk due to fever and coughing up respiratory secretions. The client with a high fever will lose fluid through the skin, which responds by vasodilation to cool off the body. Other causes of deficient fluid volume include vomiting, diarrhea, conditions that cause increased respiratory rate or urine output, insufficient IV fluid replacement, draining fistulas, or the presence of an ileostomy. Clients who have heart failure or renal failure often retain fluids and are at risk for excess fluid volume.

A client's arterial blood gases reveal a pH of 7.51 and a bicarbonate level of 31 mEq/L. The nurse prepares for the administration of which medication that should be prescribed to treat this acid-base disorder?

Acetazolamide Rationale:Acetazolamide is a diuretic used in the treatment of metabolic alkalosis. This medication causes excretion of sodium, potassium, bicarbonate, and water by inhibiting the action of carbonic anhydrase. Administration of sodium bicarbonate would aggravate the already existing condition and is contraindicated. Furosemide is a loop diuretic and spironolactone is a potassium-retaining diuretic. These are of no value when there is a need to excrete bicarbonate.

The nurse is assisting in caring for a client with severe hyponatremia resulting from hypervolemia. The nurse anticipates which treatment would be prescribed by the primary health care provider?

Administer hypertonic normal saline solution intravenously. Rationale:Normal sodium levels are 135 to 145 mEq/L (135 to 145 mmol/L). Hyponatremia is defined as a serum sodium level of less than 135 mEq/L (135 mmol/L). When hyponatremia is caused by hypervolemia, it may be treated with fluid restriction. The low serum sodium value is a result of hemodilution and the client often is impaired neurologically with altered mental status. Intravenous hypertonic saline (normal saline 3%) is reserved for hyponatremia when the serum sodium level is lower than 125 mEq/L (125 mmol/L). Administration of a blood transfusion or forcing fluids would add to the blood volume and not address the sodium problem. Potassium will not treat a sodium deficit.

A client is in respiratory alkalosis induced by gram-negative sepsis. The nurse assists in implementing which measure as the effective means to treat the problem?

Administer prescribed antibiotics. Rationale:The most effective way to treat an acid-base disorder is to treat the underlying disorder. In this case, the problem is sepsis, which is most effectively treated with antibiotic therapy. Antipyretics will control fever secondary to sepsis but do nothing to treat the acid-base disorder. The paper bag and partial rebreather mask will help the client rebreathe exhaled carbon dioxide, but again, these do not treat the primary cause of the imbalance.

The nurse is inserting an indwelling urinary catheter into a male client. As the catheter is inserted into the urethra, urine begins to flow into the tubing. When should the nurse inflate the balloon?

Advance the catheter to the bifurcation and inflate the balloon Rationale:Urinary catheterization is a sterile procedure. When inserting an indwelling catheter, the nurse should ensure the balloon is in the bladder before inflating it. If the balloon is inflated in the urethra of the male client, trauma may occur. When catheterizing a male client, the nurse observes the tubing for the flow of urine and then continues to advance the catheter to the point of bifurcation and then inflates the balloon. The nurse then pulls the catheter back until slight resistance is felt and applies a tube holder onto the thigh to hold the catheter in place. The balloon should not be inflated when urine is first observed, after advancing several more centimeters or when resistance is felt.

The nurse is preparing to administer an enema to an adult client. Which interventions should the nurse plan to perform for this procedure? Select all that apply.

Apply disposable gloves. Lubricate the enema tube and insert it approximately 4 inches. Clamp the tubing if the client expresses discomfort during the procedure Ensure that the temperature of the solution is between 100° F (37.8° C) and 105° F (40.5° C) Rationale:The administration of an enema is a clean procedure, and standard precautions must be used. The nurse applies disposable gloves when administering an enema to prevent the transfer of microorganisms. To administer an enema, the nurse places the client in the left Sims' position because the enema solution will flow downward by gravity along the natural curve of the sigmoid colon and rectum, improving retention of the enema solution. The tube is lubricated for easy insertion and is inserted approximately 3 to 4 inches in an adult. If the client complains of cramping or discomfort during the procedure, the nurse clamps the tubing until the discomfort subsides. The container containing the enema solution is hung about 12 to 18 inches above the client's anus. A flow of solution that is too forceful can damage the bowel. The temperature of the solution should be between 100° F (37.8° C) and 105° F (40.5° C). Solution that is too hot will burn the client, and solution that is too cool will cause cramping.

The client has a three-way closed continuous bladder irrigation system. Which information should be included in the documentation for this client? Select all that apply.

Character of drainage Presence of blood clots Amount of drainage emptied Client complaint of pain/spasms Type and amount of irrigation fluid used Rationale: Character of drainage, Presence of blood clots, Amount of drainage emptied, Client complaint of pain/spasms, Type and amount of irrigation fluid used are all correct because they all are indications of the effectiveness of the bladder irrigation. Character of drainage describes details such as color and sediment and is a means of evaluating effectiveness of irrigation. Presence and size description of blood clots, complaints of spasms, type and quantity of solution infused, and amount of solution returned all provide information as to effectiveness of procedure and client status. Frequency of emptying the drainage bag is incorrect because it is not necessary to document how frequently the drainage bag was emptied, but the amount of irrigation fluid that went in and the total amount of drainage emptied should be documented so that the actual urine output can be calculated by subtracting the input from the output.

After having a transurethral resection of the prostate (TURP), a client has a continuous bladder irrigation (CBI) postoperatively. The nurse notes that fluid is entering the bladder, but none appears to be draining. Select the appropriate nursing interventions. Select all that apply.

Check the bladder for distention Review intake and output record Check to ensure drainage tubing is not kinked Ask the client about bladder spasms and discomfort Rationale:A continuous bladder irrigation is often prescribed after a TURP to prevent blood clot formation that will obstruct the catheter. A drainage tube that is kinked will not allow the bladder irrigation solution to exit the body and can be done quickly while observing the system setup. Assessing the bladder for distention would follow because a clot may be preventing drainage. Asking the client if there is any discomfort or spasms may indicate improper drainage. Reviewing the intake and output record is done because the nurse can see that fluid is entering the system but not leaving. Raising the drainage bag will cause the urine to backflow into the bladder or stop flow. Deflating the balloon and advancing the catheter should not be done because this will introduce bacteria into the system.

Which clients would the nurse determine is at risk for development of metabolic alkalosis? Select all that apply.

Client who has been vomiting for 2 days Client receiving oral furosemide 40 mg daily Rationale:Metabolic alkalosis is caused by any condition that creates the acid-base imbalance through either an increase in bases or a deficit of acids, such as the client who has been vomiting for 2 days and the client receiving furosemide daily. Recall that clients with emphysema and hyperventilation are at risk for a respiratory acid-base disturbance. Chronic kidney disease and aspirin overdose will result in metabolic acidosis.

Which ostomy location would most likely need to be irrigated? Refer to figure.

D Rationale:The ostomy located at the juncture of the descending and sigmoid colon would be most likely to need irrigating because the effluent would be the most solid. Effluent in the ascending colon would be mostly liquid, and would become more solid as fluid is absorbed during passage through the transverse colon.

A client who has received sodium bicarbonate in large amounts is at risk for developing metabolic alkalosis. The nurse checks this client for which signs and symptoms characteristic of this disorder?

Decreased respiratory depth and rate and dysrhythmias Rationale:The client with metabolic alkalosis is likely to exhibit a decrease in respiratory rate and depth, nausea, vomiting, diarrhea, restlessness, numbness and tingling in the extremities, twitching in the extremities, hypokalemia, hypocalcemia, and dysrhythmias. Disorientation and dyspnea could be associated with hypoxemia. Tachypnea, dizziness, and paresthesias are often associated with hyperventilation and respiratory alkalosis. Drowsiness, headache and tachypnea are not associated with metabolic alkalosis.

The nurse is caring for a client with cirrhosis who is experiencing fluid overload. The nurse would determine that this problem is resolving if which data are obtained? Select all that apply.

Decreasing body weight Decreasing abdominal girth Rationale:A sign that fluid overload is resolving is loss of body weight and a decrease in the abdominal girth. The client with cirrhosis with resolving fluid overload will have less ascites. Assessment findings associated with excess fluid volume include cough, dyspnea, crackles, tachypnea, tachycardia, an elevated blood pressure and a bounding pulse, elevated central venous pressure, weight gain, edema, neck and hand vein distention, altered level of consciousness, decreased urine output, and a decreased hematocrit. These symptoms must reverse if the fluid overload is to be resolved.

A 3-year-old child is hospitalized because of persistent vomiting. Which conditions should the nurse expect this child to be high risk for? Select all that apply.

Dehydration Metabolic alkalosis Rationale:Vomiting will cause the loss of hydrochloric acid and subsequent metabolic alkalosis. Metabolic acidosis would occur in a child experiencing diarrhea because of the loss of bicarbonate. The child who is vomiting is also at risk for fluid volume deficit or dehydration. Diarrhea may not accompany vomiting. Hyperactive bowel sounds are not specifically associated with vomiting.

A client has the following laboratory values: a pH of 7.55, an HCO3- level of 22 mEq/L (22 mmol/L), and a Pco2 of 30 mm Hg (30 mm Hg). Which action should the nurse plan to take?

Encourage the client to slow down breathing. Rationale:The client is experiencing respiratory alkalosis based on the laboratory results of a high pH and a low Pco2 level. Interventions for respiratory alkalosis are the voluntary holding of breath or slowed breathing and the rebreathing of exhaled CO2 by methods such as using a paper bag or a rebreathing mask as prescribed. Performing Allen's test would be incorrect, because the blood specimen has already been drawn, and the laboratory results have been completed. Dialysis and insulin administration are interventions for metabolic acidosis.

A client is to be monitored for residual urine every 8 hours. Which are appropriate nursing actions for the nurse to complete this task? Select all that apply.

Have the client void and then perform the bladder scan If residual urine is less than 100 mL, continue to monitor Rationale:To obtain a residual urine, it is necessary for the client to void, then obtain a bladder scan. If less than 100 mL of urine (or the specific amount prescribed) is viewed on the scan, continuing to monitor as prescribed is appropriate. Obtaining the scan before voiding would tell the nurse how much fluid the bladder can hold. Decreasing fluids may lead to dehydration and will not affect residual urine. Notifying the primary health care provider of normal findings is inappropriate, as is catheterizing for 100 mL of residual urine.

The nurse admits a client with a diagnosis of dehydration and a positive history of cancer to the nursing unit. The client is extremely weak and has an irregular heart pulse rhythm. There are absent bowel sounds, and the client's last bowel movement was 4 days earlier. The nurse plans to review serum electrolyte levels because the client is at high risk for which electrolyte imbalance?

Hypercalcemia Rationale:The nurse will review the electrolyte results and consider the client at high risk for hypercalcemia, a calcium level higher than 10.5 mg/dL (2.75 mmol/L). The normal adult serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). A client with a history of malignancy is at risk for a high calcium level, especially if bone metastasis has occurred. Muscle weakness and heart irregularities are associated with hypercalcemia. Bowel sounds are often absent and peristalsis is seriously depressed. Hyponatremia, low sodium level, is noted to cause hyperactive bowel sounds and diarrhea. Hypocalcemia, low calcium level, is associated with tremors and hyperactive reflexes. Hypomagnesemia, low magnesium level, has similar neuromuscular effects to hypocalcemia, and often clients have painful muscle contractions.

The nurse is assigned to care for a group of clients on the clinical nursing unit. Which client is least likely to develop third spacing of fluids?

Hypertension Rationale:Fluid that shifts into the interstitial spaces and remains there is referred to as "third-space fluid." This fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Common sites for third spacing include body tissues, the pleural and peritoneal cavities and the pericardial sac. In clients with severe burns, fluid shifts out to the tissues in the area of the burn as sometimes evidenced by blistering. In clients with renal failure, there is a loss of protein due to failure of the kidney to retain protein, and fluid shifts from the blood out into the tissues causing the client to have edema in extremities and face. In Laënnec's cirrhosis the liver becomes fibrotic because of insufficient protein intake, alcoholism, and other conditions. The liver normally produces protein as albumin. With the loss of sufficient levels of albumin in clients with cirrhosis, the fluid shifts out into the abdomen (ascites) or tissues. Hypertension, elevated blood pressure, by itself is not a mechanism leading to fluid shifts. Risk factors for third spacing of fluids include the older client, and those with liver or kidney disease, major trauma, burns, sepsis, major surgery, malignancy, and gastrointestinal malabsorption and malnutrition.

The nurse is caring for an adult client with respiratory distress syndrome. A review of the arterial blood gas results indicates that the client is experiencing respiratory alkalosis. The nurse should then examine the results of serum electrolytes to see whether which electrolyte imbalance is present?

Hypokalemia Rationale:Signs and symptoms of respiratory alkalosis include a decrease in the respiratory rate and depth, headache, lightheadedness, vertigo, mental status changes, paresthesias such as tingling of the fingers and toes, hypokalemia, hypocalcemia, tetany, and seizures. Signs and symptoms do not include hyponatremia, hypercalcemia, or hyperkalemia.

The nurse is caring for a client whose magnesium level is 3 mEq/L (1.5 mmol/L) and the client is being treated for the magnesium imbalance. The nurse interprets that the electrolyte imbalance is resolving if which signs or symptoms are no longer present? Select all that apply.

Hypotension Loss of deep tendon reflexes Rationale:The normal magnesium level is 1.3 to 2.1 mEq/L (0.65-1.05 mmol/L). A client with a magnesium level of 3 mEq/L (1.5 mmol/L) is experiencing hypermagnesemia. Improvement is noted if the hypotension and loss of deep tendon reflexes have resolved. Signs of hypermagnesemia include neurological depression, drowsiness, and lethargy; loss of deep tendon reflexes; respiratory insufficiency; tachycardia and hypotension; and loss of consciousness. Tetany, muscular excitability, and twitches are seen in a client with hypomagnesemia. Chest pain is not associated with alterations in magnesium.

The nurse is assisting in the care of a client with a new ileostomy on the clinical nursing unit. Which observations indicate to the nurse that the client is at risk for fluid volume deficit? Select all that apply.

Ileostomy output of 650 mL in 4 hours Blood pressure (BP) 104/66 mmHg, temperature 98.4° F, pulse 106 beats per minute, respirations 20 breaths per minute Rationale:The client with an ileostomy is at risk for fluid volume deficit due to increased gastrointestinal tract losses. An output of 650 mL in 4 hours would amount to a loss of over 3500 mL in 24 hours. Vital signs indicate a risk with the slightly low BP (104/66 mmHg) and a slight tachycardia (106 beats per minute). The borderline normal pulse oximetry reading with crackles that clear with coughing indicates the client may be breathing shallowly and developing atelectasis. The normal skin turgor is not indicative of risk for fluid volume deficit.

An older client complains of chronic constipation. Which instructions should the nurse reinforce with the client? Select all that apply.

Increase fluids to at least eight glasses a day. Respond in a timely manner to the urge to defecate. Rationale:Increase of fluid intake and dietary fiber will help change the consistency of the stool and make it easier for the client to pass. Clients should respond to the feeling of peristalsis involved with urge to defecate. Some older clients with mobility issues may not respond to the urge. Increasing the intake of rice and bananas will increase constipation. Increasing sugar-free products and potassium in the diet will not be beneficial to the client.

A client receiving iron supplements is complaining of constipation and the stool that is passed is black. Which information is appropriate for the nurse to share with the client? Select all that apply.

Increase your fluid intake Include more fiber in your diet Ferrous sulfate changes the color of stool to black Iron slows colonic acid and often leads to constipation Rationale:As motility slows, feces are exposed to the intestinal walls and water is absorbed. Increasing fluid intake will help by adding more fluid to the intestinal contents. Fiber increases motility. Iron and several other medications slow motility. Lack of exercise or bed rest contributes to constipation. An enema should not be used every other day, usually no more frequently than on the third day. Many people do not have bowel movements every day. Constipation is not having a bowel movement in 3 days.

The nurse is caring for a client who has been taking diuretics on a long-term basis. Which finding should the nurse expect to note as a result of this long-term use?

Increased specific gravity of the urine Rationale:Clients taking diuretics on a long-term basis are at risk for fluid volume deficit. Findings of fluid volume deficit include increased respiration and heart rate, decreased central venous pressure, weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, dark-colored and odorous urine, an increased hematocrit level, and an altered level of consciousness. Gurgling respirations, increased blood pressure, and decreased hematocrit as a result of hemodilution are seen in a client with fluid volume excess.

The nurse is caring for a client with a diagnosis of hyperparathyroidism. Laboratory studies are performed and the serum calcium level is 12.0 mg/dL (3.0 mmol/L). Based on this laboratory value, the nurse should take which action?

Inform the registered nurse of the laboratory value. Rationale:The normal serum calcium level ranges from 9 to 10.5 mg/dL (2.25-2.75 mmol/L). The client is experiencing hypercalcemia and the nurse would inform the registered nurse of the laboratory value. Because the client is experiencing hypercalcemia, the remaining options are incorrect actions.

A 0.9% intravenous (IV) solution is prescribed for a client. The IV is to run at 100 mL/hr. The nurse prepares the solution, understanding that which are characteristics of this type of solution? Select all that apply.

Is the same solution as sodium chloride 0.9% Is used to administer red blood cell transfusion Is used to treat hypotension due to fluid volume deficit Rationale:Sodium chloride 0.9%, also referred to as normal saline 0.9%, is isotonic. Isotonic solutions frequently are used for intravenous infusion because they have the same osmolarity as blood. Isotonic IV solutions do not affect the plasma osmolarity. The solution is used for administration in blood transfusions because it will not affect the blood cells. Because the fluid stays in the circulation, isotonic fluids are given to treat hypotension.

The nurse observes that a client with diabetic ketoacidosis is experiencing abnormally deep, regular, rapid respirations. How should the nurse correctly document this observation in the medical record?

Kussmaul's respirations Rationale:Abnormally deep, regular, and rapid respirations observed in the client with diabetic ketoacidosis are documented as Kussmaul's respirations. During apnea, respirations cease for several seconds. During bradypnea, respirations are regular but abnormally slow. Cheyne stokes respirations gradually become more shallow and are followed by periods of apnea (no breathing), with repetition of the pattern.

The nurse is assisting in the care of a client with a left foot that sustained a crush injury. The nurse determines that the client developed third spacing of body fluid based on which observation?

Left foot has 4+ pitting edema Rationale:Fluid that shifts into the interstitial spaces and remains there is referred to as third-space fluid. This fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Common sites for third spacing include tissues where an injury or burn occurred, the pleural and peritoneal cavities, and the pericardial sac. Clients at high risk for third spacing include older adults and those with liver or kidney disease, major trauma, burns, sepsis, major surgery, malignancy, gastrointestinal malabsorption, and malnutrition. The left foot that was crushed and is grossly edematous is an example of third spacing of body fluid. The blood pressure represents intravascular fluid status. Normal skin turgor and slight abdominal distention are not examples of third-spacing of fluids.

A client presents to the emergency department with lethargy; deep, regular respirations; and a fruity odor to the breath. The client's arterial blood gas (ABG) results are pH of 7.25, Pco2 of 34 mm Hg, Po2 of 86 mm Hg, and HCO3- of 14 mEq/L. The nurse interprets that the client has which acid-base disturbance?

Metabolic acidosis Rationale:Acidosis is defined as a pH of less than 7.35, and alkalosis is defined as a pH greater than 7.45. Respiratory acidosis is present when the Pco2 is greater than 45, and respiratory alkalosis is present when the Pco2 is less than 35. Metabolic acidosis is present when the pH is less than 7.35 and the HCO3- is less than 22 mEq/L, whereas metabolic alkalosis is present when the pH is greater than 7.45 and the HCO3- is greater than 27 mEq/L. This client's ABGs are consistent with metabolic acidosis. With a slightly alkalotic level of carbon dioxide there is evidence of some incomplete compensation.

A client underwent creation of an ileostomy 2 days ago. The nurse checks the client for signs of which acid-base disorder that a client with an ileostomy is at risk for developing?

Metabolic acidosis Rationale:Intestinal secretions are high in bicarbonate because of the effects of pancreatic secretions. These fluids may be lost from the body before they can be reabsorbed with conditions such as diarrhea or creation of an ileostomy. The decreased bicarbonate level creates the actual base deficit of metabolic acidosis. The client with an ileostomy is not at risk for developing the acid-base disorders such as respiratory alkalosis or acidosis or metabolic alkalosis.

The nurse is caring for a client with severe diarrhea. The nurse monitors the client closely, understanding that this client is at risk for developing which acid-base disorder?

Metabolic acidosis Rationale:Intestinal secretions high in bicarbonate may be lost through enteric drainage tubes, an ileostomy, or diarrhea. The decreased bicarbonate level creates the actual base deficit of metabolic acidosis.

The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client closely for which acid-base disorder that is most likely to occur in this situation?

Metabolic alkalosis Rationale:The loss of gastric fluid via nasogastric suction or vomiting causes a metabolic condition. This also results in an alkalotic condition as a result of the loss of hydrochloric acid through gastrointestinal fluid losses. Also, the options denoting a respiratory problem—respiratory acidosis and alkalosis—can be easily eliminated.

The nurse is reviewing the laboratory results of a client hospitalized with a diagnosis of Crohn's disease. The client has a magnesium level of 1.0 mEq/L (0.5 mmol/L). Which nursing interventions should the nurse initiate? Select all that apply.

Monitor the client for dysrhythmias. Notify the primary health care provider (PHCP) of the laboratory results. Rationale:Magnesium is important for cellular function, metabolism, and skeletal and cardiac muscle function. Normal levels for an adult are 1.3 to 2.1 mEq/L (0.65-1.05 mmol/L). Hypomagnesemia is defined as a plasma magnesium level less than 1.3 mEq/L (0.65 mmol/L). The nurse should notify the PHCP so treatment can be initiated to correct the problem as soon as possible. The client should be monitored for dysrhythmias because the client is predisposed particularly to ventricular dysrhythmias. The client also should consume foods high in magnesium such as beans. Bananas are high in potassium, not magnesium. Because hypocalcemia frequently accompanies hypomagnesemia, high-calcium foods should be consumed, but this will not treat the low magnesium.

A client enters the emergency department confused, twitching, and having seizures. His family states he recently was placed on corticosteroids for arthritis and was feeling better and exercising daily. On data collection, he has flushed skin, dry mucous membranes, an elevated temperature, and poor skin turgor. His serum sodium level is 150 mEq/L (150 mmol/L). Which interventions would the primary health care provider likely prescribe? Select all that apply.

Monitor vital signs Monitor electrolyte levels Monitor intake and output Increase water intake orally Maintain sodium-reduced diet Rationale:Hypernatremia is described as having a serum sodium level that exceeds 145 mEq/L (145 mmol/L). The normal serum sodium level for an adult is 135 to 145 mEq/L (135 to 145 mmol/L). Signs and symptoms would include dry mucous membranes, loss of skin turgor, thirst, flushed skin, elevated temperature, oliguria, muscle twitching, fatigue, confusion, and seizures. Interventions include monitoring fluid balance, monitoring vital signs, reducing dietary intake of sodium, monitoring electrolyte levels, and increasing oral intake of water. Sodium replacement therapy would not be prescribed for a client with hypernatremia. Hypertonic saline is prescribed for severe hyponatremia.

A client enters the emergency department confused, twitching, and having seizures. Upon assessment, flushed skin, dry mucous membranes, an elevated temperature, and poor skin turgor is noted. The serum sodium level is 172 mEq/L (172 mmol/L). Which interventions should the primary health care provider (PHCP) likely prescribe? Select all that apply.

Monitor vital signs. Monitor intake and output. Increase water intake orally Monitor electrolyte levels Provide a sodium-reduced diet. Rationale:Hypernatremia is described as having a serum sodium level that exceeds 145 mEq/L (145 mmol/L). Signs and symptoms would include dry mucous membranes, loss of skin turgor, thirst, flushed skin, elevated temperature, oliguria, muscle twitching, fatigue, confusion, and seizures. Interventions include monitoring fluid balance, monitoring vital signs, reducing dietary intake of sodium, monitoring electrolyte levels, and increasing oral intake of water. Sodium replacement therapy would not be prescribed for a client with hypernatremia.

The nurse is monitoring the fluid balance of a client with advanced human immunodeficiency virus (HIV) infection. Because the client has lost a great deal of weight and muscle mass, the nurse understands that which action will provide a reliable indicator of fluid balance?

Monitoring for decreased urine output and hypotension Rationale:With the loss of muscle mass and adipose tissue, the overlying skin loses its support. The usual elasticity of skin becomes a less reliable indicator of body fluid status. Vomiting and diarrhea may cause weight loss and electrolyte imbalances, but the amount that is vomited does not precisely correlate with the amount of fluid remaining in the body because systems such as the kidney can help reestablish equilibrium. Decreased urine output and hypotension more accurately correlate with loss of fluid and chronic illness in clients with HIV.

The nurse reviews a client's electrolyte results and notes that the potassium level is 5.4 mEq/L (5.4 mmol/L). What should the nurse look for on the cardiac monitor as a result of this laboratory value?

Narrow, peaked T waves Rationale:A serum potassium level of 5.4 mEq/L is indicative of hyperkalemia. Cardiac changes include a wide, flat P wave; a prolonged PR interval; a widened QRS complex; and narrow, peaked T waves.

Which factors contribute to the problem of stress incontinence? Select all that apply.

Obesity Sneezing Rationale:Obesity contributes to stress incontinence by causing increased intra-abdominal pressure. Sneezing or laughing also often cause leakage of urine due to sudden increased intra-abdominal pressure. Nulliparity refers to never having given birth and is not a factor of stress incontinence; rather, a history of having three or more vaginal births is associated with stress incontinence due to the weakening of the pelvic floor muscles. Performing Kegel exercises is actually a means of strengthening muscle tone. Voiding at frequent intervals, such as every 2 hours decreases the volume of urine in the bladder, thus decreasing the stretch and pressure in the bladder, and lessening the chance of incontinence.

The nurse has assisted with obtaining a blood specimen for arterial blood gas (ABG) analysis. The nurse avoids doing which to properly obtain and send the specimen?

Obtain a 3-mL syringe that is used for parenteral medication. Rationale:The specimen is drawn into a heparinized syringe to prevent clotting of the blood. A 3-mL syringe used to administer parenteral medication is not used. The specimen should be placed on ice after it is obtained. The requisition is fully completed, identifying pertinent client information such as body temperature and amount of oxygen in use.

A client presents in the emergency department reporting severe nausea, vomiting, and diarrhea for 5 days. The client is weak, has 2+ tenting skin turgor, and states a weight loss of 7 pounds in the last week. At this time, which action would the nurse take?

Obtain orthostatic vital signs. Rationale:The initial nursing action is to determine the client's level of dehydration. Orthostatic vital signs (blood pressures and pulses, lying, sitting, standing) are actions to determine the probability of fluid losses. A drop of more than 10 to 20 mm Hg and an increased pulse rate of 10 to 20 beats per minute probably indicate a significant intravascular fluid volume deficit. With a significant history of nausea, vomiting, and diarrhea accompanied by weight loss, the client is facing a life-threatening problem. Generally, the fluid levels must be increased quickly with lactated Ringer's or normal saline intravenous solutions as prescribed. Check the client's skin for irritation caused by diarrhea may be an intervention, but it is not the initial action. Prepare to insert a nasogastric tube feeding and prepare to insert a parenteral nutrition infusion. are not initial measures to treat dehydration.

The nurse observes a student nurse using a bladder scanner to determine a postoperative hysterectomy client's post-void residual (PVR). Which actions observed demonstrate the need for further teaching? Select all that apply.

Placing the scan head on the symphysis pubis and aiming toward the bladder. Applying a generous amount of transmission/conductivity gel across the client's abdomen. Rationale:A bladder scan is a portable ultrasound used to estimate the amount of urine in the bladder. The student nurse should apply the conductivity gel 2.5 to 4 cm above the symphysis pubis, not across the abdomen. The scan head is placed in this area and aimed toward the client's head and slightly downward toward the coccyx, not downward on the symphysis pubis. The supine position is correct. The scanner is turned on and the male setting is used with a female client without a uterus (status post hysterectomy). The scan head is cleansed with alcohol before the scan. Once the scanner head is positioned the button is pushed to display the urine in the bladder. The nurse observes the picture on the scanner to make sure the picture on the screen correctly depicts the urine. The volume measurement is printed or noted and documented in the client's medical record. The client needs to be placed in the proper position before the scanner is turned on and gender is selected. After applying gel, the bladder can be scanned. Once the bladder is scanned, the volume measurement should be displayed and the results printed.

A client is at risk for developing hypocalcemia. The nurse determines which signs are associated with this electrolyte disturbance? Select all that apply.

Positive Trousseau's sign Fine tremors noted in hands Rationale:Normal calcium levels are 9 to 10.5 mg/dL (2.25-2.75 mmol/L). Signs of hypocalcemia, calcium less than 9.0 mg/dL (2.25 mmol/L), include a positive Trousseau's sign (applying a blood pressure cuff and pumping it up above the systolic BP for 3 to 5 minutes results in a carpal spasm or palmar flexion) and increased neuromuscular excitability causing fine tremors when holding the hands out. Additional signs of hypocalcemia include paresthesias, hyperactive reflexes, Chvostek's sign (striking the side of the face and noting twitching), a decreased heart rate, hypotension, hyperactive bowel sounds, muscle cramps, tetany, seizures, insomnia, irritability, memory impairment, and anxiety. Increased blood pressure, increased heart rate, and hypoactive bowel sounds are all signs of hypercalcemia.

The nurse is caring for a client with leukemia and notes that the client has poor skin turgor and flat neck and hand veins. The nurse suspects hyponatremia. Which additional sign/symptom should the nurse expect to note in this client if hyponatremia is present?

Postural blood pressure changes Rationale:Postural blood pressure changes occur in the client with hyponatremia. Intense thirst and dry mucous membranes are seen in clients with hypernatremia. A slow, bounding pulse is not indicative of hyponatremia. In a client with hyponatremia, a rapid, thready pulse is noted.

The metabolic panel of a client reveals a calcium level of 6.5 mg/dL (1.6 mmol/L). Based on this laboratory finding, which additional data specific to this calcium level should the nurse collect? Select all that apply.

Presence of Chvostek's sign Presence of electrocardiogram abnormalities Presence of tingling in the fingertips and around the mouth Presence of carpal spasm when blood pressure cuff is inflated above systolic blood pressure for a few minutes Rationale:The laboratory result reveals hypocalcemia, a lower than normal calcium level. The normal adult serum calcium level is 9 to 10.5 mg/dL (2.25 to 2.75 mmol/L). Tetany, electrocardiogram abnormalities, and tingling can be present in hypocalcemia. To test for tetany, the nurse should check for a positive Chvostek's sign (contraction of facial muscles in response to a light tap over the facial nerve in front of the ear) and Trousseau's sign (checking for a carpal spasm induced by inflating a blood pressure cuff over the systolic blood pressure for a few minutes). Muscle weakness is commonly associated with potassium abnormalities. Decreased deep tendon reflexes are associated with both hypercalcemia and hypermagnesemia.

The nurse reviews the client's serum calcium level and notes that the level is 8.0 mg/dL (2.0 mmol/L). The nurse understands that which condition would cause this serum calcium level?

Prolonged bed rest Rationale:The normal serum calcium level is 9 to 10.5 mg/dL (2.25-2.75 mmol/L). A client with a serum calcium level of 8.0 mg/dL (2.0 mmol/L) is experiencing hypocalcemia. The excessive ingestion of vitamin D, adrenal insufficiency, and hyperparathyroidism are causative factors associated with hypercalcemia. Although immobilization can initially cause hypercalcemia, the long-term effect of prolonged bed rest is hypocalcemia.

A client needs to be placed on strict intake and output (I&O) measurement. The nurse collects the data as a baseline and then checks the client's skin turgor by doing which action?

Pulling up and releasing the skin on the sternal area Rationale:When preparing to place a client on I&O measurement, the nurse explains the procedure to the client. This will provide the client with information about the purpose and procedure and allow client participation, if feasible, such as contacting the nurse when oral intake is consumed or if the bathroom is used. The nurse also performs a baseline assessment for later comparison and checks for signs of fluid imbalance, including measuring the client's vital signs, weight, and skin turgor. Skin turgor is the skin's elasticity. To assess turgor, a fold of skin is grasped on the back of the forearm or sternal area with the fingertips and released. Normally the skin lifts easily and snaps back to its resting position. The skin stays pinched when turgor is poor. The actions in manipulating the skin near the thigh, ankle, or wrist are not approved interventions to assess turgor.

The nurse reviews the arterial blood gas results of a client and notes that the results indicate a pH of 7.30, Pco2 of 52 mm Hg, and HCO3- of 22 mEq/L. Which interpretation should the nurse correctly make about these results?

Respiratory acidosis Rationale:Normal pH is 7.35 to 7.45. In a respiratory condition, an opposite effect will be seen between the pH and the Pco2. In this situation, the pH is low and the Pco2 is increased. In an acidotic condition, the pH is decreased. Therefore, the values identified in the question indicate a respiratory acidosis.

Arterial blood gases (ABGs) are obtained on a client with pneumonia. The ABG results are pH, 7.50; Pco2, 30 mm Hg; HCO3-, 20 mEq/L; and Po2, 75 mm Hg. The nurse interprets these results and determines that which acid-base condition exists?

Respiratory alkalosis Rationale:Normal pH is 7.35 to 7.45. Normal Pco2 is 35 to 45 mm Hg. Remember that when a respiratory condition exists, an opposite effect will be found between the pH and the Pco2. In respiratory alkalosis, the pH will be elevated and the Pco2 level decreased.

A client who has fallen from a roof and fractured his ribs has arterial blood gas (ABG) results of: pH 7.48, Paco2 32 mm Hg, Pao2 89 mm Hg, and HCO3- 22 mEq/L. How should the nurse interpret the client's blood gas results?

Respiratory alkalosis Rationale:The client has respiratory alkalosis. Normal ranges for pH are 7.35 to 7.45, for Paco2 35 to 45 mm Hg, and for bicarbonate 22 to 26 mEq/L. With acidosis, the pH would be less than 7.35; with alkalosis, the pH would be greater than 7.45. Carbon dioxide levels would be elevated in respiratory acidosis. Bicarbonate levels would be low if a metabolic acidosis is present.

The nurse is told that the arterial blood gas (ABG) results indicate a pH of 7.50 and a Pco2 of 32 mm Hg (32 mm Hg). The nurse determines that these results are indicative of which acid-base disturbance?

Respiratory alkalosis Rationale:The normal pH is 7.35 to 7.45. If a respiratory condition exists, an opposite relationship will be seen between the pH and the Pco2, as is seen in the correct option. If an alkalotic condition exists, the pH is increased. During an acidotic condition, the pH is decreased so both metabolic acidosis and respiratory acidosis can be eliminated. Metabolic alkalosis can also be eliminated because both pH and HCO3- are increased above normal values with this condition.

A client has a serum sodium level of 129 mEq/L (129 mmol/L) because of hypervolemia. The nurse anticipates the primary health care provider to prescribe which measures? Select all that apply.

Restrict fluid intake. Monitor electrolytes every 24 hours. Rationale:Hyponatremia is defined as a serum sodium level of less than 135 mEq/L (135 mmol/L). Normal serum sodium levels are 135 to 145 mEq/L (135 to 145 mmol/L). When it is caused by hypervolemia, it may be treated with fluid restriction. The low serum sodium value is a result of hemodilution. The serum electrolytes will be monitored daily to determine effectiveness of treatment. There is no indication that the oral intake should be withheld from the client. Salt tablets would not be indicated because the sodium will likely increase to a normal level with the fluid restriction. A 4-g sodium diet is a no-added-salt diet. Intravenous hypertonic saline (3%) is reserved for hyponatremia when the serum sodium level is lower than 125 mEq/L (125 mmol/L).

A client has been diagnosed with functional incontinence. Which interventions are most appropriate to care for this type of incontinence? Select all that apply.

Schedule toileting every 2 hours Modify clothing for easy removal Assess environment for obstacles Set up schedule of cues such as mealtimes, awakening, and bedtime Rationale:Functional incontinence is loss of urine by factors outside the urinary tract that interfere with the ability to respond in a socially appropriate way to the urge to void. It may be an inability or unwillingness of a person with normal bladder function to get to the bathroom in time, environmental barriers (e.g., raised side rails), physical limitations (e.g., can't walk self to bathroom), or mental factors (e.g., disorientation). Interventions include such things as clothing modifications, environmental alterations, scheduled toileting, and absorbent products. Therefore, Modify clothing for easy removal is correct because modifying clothing to use Velcro or easy fasteners can save time in reacting to urge. Schedule toileting every 2 hours is correct because toileting every 2 hours will prevent overfilling of the bladder. Assess environment for obstacles is correct because environmental obstacles such as poor lighting or lack of assistive devices can make it difficult to reach the toilet in a timely manner. Set up schedule of cues such as mealtimes, awakening, and bedtime. is correct because establishing a schedule will provide reminders to use the toilet. Decrease fluid intake to 1500 mL/day is incorrect because decreasing fluid intake to below 2000 mL will irritate the bladder and may contribute to incontinence and may increase risk of infection. Obtain prescription for catheterization to eliminate embarrassment, catheterization, is incorrect because it contributes to risk of infection.

The nurse reviews an assigned client's laboratory report and notes a serum potassium level of 5.5 mEq/L (5.5 mmol/L). The nurse should determine that this is an expected finding if the client had which health problems? Select all that apply.

Severe burn injury Untreated ketoacidosis Rationale:The normal serum potassium level for an adult is 3.5 to 5.0 mEq/L (3.5 to 5 mmol/L). A serum potassium level greater than 5.0 mEq/L (5.0 mmol/L) indicates hyperkalemia. This electrolyte imbalance is likely to occur in clients who experience cellular shifting of potassium from early massive cell destruction as in trauma or burns. Potassium is mostly intracellular so the cell destruction releases potassium into the blood. Other clients at risk for hyperkalemia are those with sepsis or metabolic or respiratory acidosis. The body physiologically responds to acidosis by moving hydrogen ions intracellularly and potassium ions extracellularly to compensate and maintain a normal pH (7.35 to 7.45). The client with Cushing's syndrome, ulcerative colitis, or diarrhea is at risk for hypokalemia.

Which fluids are identified as insensible fluid losses? Select all that apply.

Sweat Sputum Rationale:Insensible fluid losses are those that cannot be perceived by the senses or measured because they occur through the skin, such as sweat, and the lungs, such as sputum. They occur on a daily basis without the client's awareness. Sensible losses are those that are perceivable and measurable and include wound drainage, including output from wound drains such as a Jackson-Pratt drain; gastrointestinal tract losses, such as output from a nasogastric tube; and urine output.

Etidronate, an antihypercalcemic medication, is prescribed for a client. Which information should the nurse reinforce when instructing the client about taking this medication?

Take 2 hours before meals. Rationale:Etidronate is a bisphosphonate that works by slowing the resorption of bone and allowing new bone to be formed. Etidronate should be taken on an empty stomach 2 hours before meals. It should not be taken within 2 hours of vitamins, mineral supplements, antacids, or medications high in calcium, magnesium, iron, or albumin.

A primary health care provider (PHCP) has written a prescription for calcium carbonate for the client with hypocalcemia. The nurse is reinforcing teaching with the client and should include which instructions? Select all that apply.

Take the calcium carbonate with or just after meals. Avoid foods such as beets, spinach, and bran in the diet. Take the medication with a full glass of water (8 oz/240 mL). Rationale:Calcium carbonate is best absorbed with or just after meals. Foods that are high in oxalate, such as beets and spinach, or insoluble fiber, such as bran, may interfere with calcium absorption if eaten in excess. The medication should be taken with a full glass of water (8 oz/240 mL). Chewable tablets should be chewed and taken with a full glass of water to improve absorption of the calcium. The client should follow the prescribed dose and contact the PHCP if symptoms such as tremors occur.

The nurse should recognize that which type of enema has the highest risk of water intoxication?

Tap water Rationale:Tap water is hypotonic, creating a lower osmotic pressure than the fluid in interstitial spaces. With repeated tap water enemas, fluid can escape from the bowel lumen into interstitial spaces and can cause circulatory overload or water intoxication if the body absorbs too much water. Normal saline enemas are the safest type of enema because of having the same osmotic pressure as fluid in the interstitial spaces around the bowel. Thus, enemas using normal saline do not cause any fluid shifts but may not be effective in evacuating the bowel. Castile soap is incorrect because it can be mixed with either water or saline, and if mixed with saline, there should not be any risk of fluid overload. Castile soap is the only safe soap to use for a soapsuds enema because harsh soaps may cause inflammation of the bowel. Hypertonic solution is incorrect because hypertonic fluids pull fluid from the interstitial spaces into the colon. Although this could have the potential for dehydration, it does not pose as high of a risk of complications as the tap water enema. A Fleets enema (commercially prepared sodium phosphate) is the most common type of hypertonic enema.

The nurse is told in a report that the client has hypocalcemia. Which signs should the nurse expect to note during the data collection? Select all that apply.

Tetany A positive Chvostek's sign A positive Trousseau's sign Rationale:Calcium is an electrolyte that is necessary for muscle movement. The adult normal calcium level is 9 to 10.5 mg/dL (2.25-2.75 mmol/L). A low calcium tends to cause muscle irritability. A positive Chvostek's sign (striking the side of the face and noting twitching) and positive Trousseau's sign (applying a blood pressure cuff and pumping it up above the systolic BP for 3 to 5 minutes results in a carpal spasm or palmar flexion) are indicative of hypocalcemia. Other signs and symptoms include tachycardia, hypotension, paresthesia, twitching, cramps, tetany, seizures, hyperactive bowel sounds, and a prolonged QT interval on the electrocardiogram rhythm.

The nurse is reading the primary health care provider's (PHCP's) progress notes in the client's record and sees that the PHCP has documented "insensible fluid loss of approximately 800 mL daily." Which client is at risk for this loss?

The client with a fast respiratory rate Rationale:Sensible losses are those that the person is aware of, such as those that occur through wound drainage, gastrointestinal (GI) tract losses, and urination. Insensible losses may occur without the person's awareness. Insensible losses occur daily through the skin and the lungs.

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at risk for fluid volume deficit?

The client with a ileostomy Rationale:Causes of a fluid volume deficit include vomiting, diarrhea, conditions that cause increased respirations or increased urinary output, insufficient intravenous fluid replacement, draining fistulas, ileostomy, and ileostomy. A client with cirrhosis, heart failure (HF), or decreased kidney function is at risk for fluid volume excess.

The nurse is caring for a group of clients on a clinical nursing unit. The nurse interprets that which assigned clients are at risk for excess fluid volume? Select all that apply.

The client with chronic cirrhosis The client with renal failure Rationale:The client with renal failure is most at risk for excess fluid volume because of the inability of the kidneys to excrete fluid. The client with chronic cirrhosis is at risk for fluid volume excess due to fluid retention secondary to portal hypertension and low levels of protein. Other causes of excess fluid volume include heart failure, liver disorders, excessive use of hypotonic intravenous (IV) fluids to replace isotonic losses, excessive irrigation of body fluids, and excessive ingestion of table salt. The client with an ileostomy, a draining abdominal wound, or a nasogastric tube attached to suction is at risk for deficient fluid volume.

The nurse is reviewing the health records of assigned clients. The nurse should plan care knowing that which client is at the least likely risk for the development of third-spacing?

The client with diabetes mellitus Rationale:Fluid that shifts into the interstitial space and remains there is referred to as third-space fluid. Common sites for third-spacing include the abdomen, pleural cavity, peritoneal cavity, and pericardial sac. Third-space fluid is physiologically useless because it does not circulate to provide nutrients for the cells. Risk factors include liver or kidney disease, major trauma, burns, sepsis, wound healing, major surgery, malignancy, malabsorption syndrome, malnutrition, alcoholism, and older age.

The nurse is administering a cleansing enema to a client with a fecal impaction. Before administering the enema, the nurse asks the client to assume a left Sims' position. The nurse explains that this positioning is preferred because of which reason?

The enema will flow into the bowel easily Rationale:When administering an enema, the client is placed in a left Sims' position so that the enema solution can flow by gravity in the natural direction of the colon. The anatomy of the colon consists of ascending on the right, transverse across, with descending on the left leading to the sigmoid and rectum. If the client lies on the left side, the enema solution will flow easily into the bowel. The hand dominance of the nurse is not a factor. The nurse assists the client to relax the rectal sphincter by asking the client to take a deep breath. The nurse assists the client to retain the enema solution by administering the enema slowly. The nurse should also use teach-back to determine client's understanding about the reason for the enema.

The nurse who is caring for a client with kidney failure notes that the client is dyspneic and crackles are heard when listening to breath sounds in the lungs. Which additional sign/symptom should the nurse expect to note in this client?

An increase in blood pressure Rationale:Impaired cardiac or kidney function can result in fluid volume excess. Findings associated with fluid volume excess include cough, dyspnea, crackles, tachypnea, tachycardia, an elevated blood pressure, a bounding pulse, an elevated central venous pressure, weight gain, edema, neck and hand vein distention, an altered level of consciousness, and a decreased hematocrit level.

The nurse is caring for a client with hyperparathyroidism and notes that the client's serum calcium level is 13 mg/dL (3.25 mmol/L). Which prescribed medication should the nurse plan to assist in administering to the client?

Calcitonin Rationale:The normal serum calcium level is 9 to 10.5 mg/dL (2.2.5-2.75 mmol/L). This client is experiencing hypercalcemia. Calcium gluconate and calcium chloride are medications used for the treatment of tetany, which occurs as a result of acute hypocalcemia. In hypercalcemia, large doses of vitamin D need to be avoided. Calcitonin, a thyroid hormone, decreases the plasma calcium level by inhibiting bone resorption and lowering the serum calcium concentration.

The nurse is caring for a client with a suspected diagnosis of hypercalcemia. Which sign/symptom would be an indication of this electrolyte imbalance?

Generalized muscle weakness Rationale:Generalized muscle weakness is seen in clients with hypercalcemia. Twitching, positive Trousseau's sign, and hyperactive bowel sounds are signs of hypocalcemia.

The primary health care provider prescribes a three-way bladder irrigation of normal saline. Over an 8-hour shift, 250 mL has infused from the normal saline. There is 1850 mL in the collection receptacle at the conclusion of the 8-hour shift. Which is the client's true urine output for the shift? Fill in the blank.

250 mL Rationale:200 mL × 8 hr = 1600 mL, which is the amount of normal saline infused. 850 − 1600 = 250 (total in receptacle minus irrigation)

The nurse determines that which clients are at high risk for metabolic acidosis? Select all that apply.

Clients with diabetes Clients with kidney failure Clients with malnourishment Rationale:Diabetes mellitus, kidney failure, and malnutrition lead to metabolic acidosis by increasing acids in the body. Asthma, pneumonia, and severe anxiety lead to respiratory, not metabolic, imbalances.

Which information should the nurse include when reinforcing client teaching regarding ostomy care? Select all that apply.

Empty pouch when ⅓ to ½ full The stoma should be moist and pink to red The skin barrier should be within 1⁄16 to ⅛ inch of the stoma Change the appliance about every 3 days, or sooner, if it is leaking effluent Rationale:The pouch should be emptied when ⅓ to ½ full to prevent the weight of contents from loosening the seal. The stoma should be moist and pink to red in color. Keeping the skin barrier to within 1⁄16 to ⅛ inch of the base of the stoma prevents effluent from irritating the skin. With an adequate seal, changing the appliance every 3 days is adequate and may be done as infrequently as 2 weeks. Changing the appliance daily would damage the skin around the stoma. A dry pale pink is indicative of an unhealthy stoma and possibly dehydration.

A client is admitted with a diagnosis of pneumonia and dehydration. The nurse monitors the client and determines which symptoms correlate with this client's fluid imbalance? Select all that apply.

Flat neck veins Weakly palpable peripheral pulses Heart rate of 104 beats per minute Rationale:A client with dehydration has a fluid volume deficit, which can be reflected by flat neck veins, a slightly tachycardic pulse rate (104 beats per minute), and weakly palpable peripheral pulses. Other findings are increased respirations, weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, concentrated urine with increased specific gravity, increased hematocrit, and altered level of consciousness. The lung crackles are consistent with consolidation in the lungs occurring with pneumonia and the borderline elevated BP may relate to pain associated with breathing.

A client has a nasogastric tube in place that is attached to suction. The client is at risk for developing which electrolyte imbalances with prolonged suction? Select all that apply.

Hypokalemia Hyponatremia Hypomagnesemia Rationale:Prolonged gastric suction can result in electrolyte imbalances. There can be deficits of potassium, sodium, or magnesium blood levels.

The nurse is observing a client who is independently performing the application of an ostomy appliance for the first time. Which actions observed demonstrate the need for further teaching? Select all that apply.

Lightly scrub the stoma with soap and water Cut the opening on the appliance ½ inch larger than stoma Rationale:The client washes the hands and dons gloves before removing the pouch and barrier. The peristomal area is cleansed with warm water to remove residue and improve visualization. The stoma is assessed for color, and the skin is checked for irritation. The appliance is measured and cut 1/16 inch larger than stoma to prevent strangulation of stoma, or too much room for skin irritation between the stoma and appliance. The adhesive backing of the appliance is pressed against the skin avoiding wrinkles to achieve seal

The nurse is collecting data from a client with a suspected diagnosis of gastric ulcer. The client tells the nurse that oral antacids are taken frequently throughout the day. The nurse continues to collect data from the client, understanding that the client is at risk for which acid-base disturbance?

Metabolic alkalosis Rationale:Increases in base components occur as a result of oral or parenteral ingestion of bicarbonates, carbonates, acetates, citrates, and lactates. Excessive use of oral antacids containing sodium or calcium bicarbonate can cause metabolic alkalosis. Eliminate the options dealing with respiratory problems. Eliminate acidosis because of the ingestion of antacids.

The nurse is caring for a client with a diagnosis of chronic obstructive pulmonary disease (COPD). The nurse should monitor the client for which acid-base imbalance?

Respiratory acidosis Rationale:Respiratory acidosis most often occurs as a result of primary defects in the function of the lungs or changes in normal respiratory patterns from secondary problems. Chronic respiratory acidosis is most commonly caused by chronic obstructive pulmonary disease (COPD). Acute respiratory acidosis also occurs in clients with COPD when superimposed respiratory infection or concurrent respiratory disease increases the work of breathing. The remaining options are not likely to occur unless other conditions complicate the COPD.

The nurse evaluates that there is a need for further teaching on bowel elimination when the client makes which statement?

"I need to decrease fiber in my diet." Rationale:Adequate dietary fiber is an important factor for improving bowel function. Dietary fiber increases fecal weight and water content and accelerates the transit of the fecal mass through the gastrointestinal (GI) tract. The retention of water by the fiber has the ability to soften stools and promote regularity. Fluid intake and exercise also facilitate bowel elimination.

The nurse is instructing a client on how to decrease the intake of calcium in the diet. The nurse should tell the client that which food item is least likely to contain calcium?

Butter Rationale:Butter comes from milk fat and does not contain significant amounts of calcium. Milk, spinach, and collard greens are calcium-containing foods and should be avoided by the client on a calcium-restricted diet.

The nurse is caring for a client with kidney failure. The laboratory results reveal a magnesium level of 3.6 mEq/L (1.8 mmol/L). Which sign should the nurse expect to note in the client, based on this magnesium level?

Loss of deep tendon reflexes Rationale:The normal magnesium level is 1.3 to 2.1 mEq/L (0.65 to 1.05 mmol/L). A client with a magnesium level of 3.6 mEq/L (1.8 mmol/L) is experiencing hypermagnesemia. Loss of deep tendon reflexes is characteristic of this condition. Twitching, irritability, and hyperactive reflexes should be noted in a client with hypomagnesemia.

The nurse is discharging a postoperative female client who had a urinary tract infection (UTI) after surgery. Which essential issues about UTIs should the nurse reinforce in the discharge instructions? Select all that apply.

Maintain adequate fluid intake of 2 quarts. Avoid vaginal douches and/or harsh soaps, bubble baths, powders, and sprays in the perineal area. Take all discharge medication as prescribed including antibiotics, and notify your primary health care provider if symptoms or signs of a UTI reappear. Use good hygiene including cleaning the perineum by separating the labia, cleaning with warm soapy water after a bowel movement, and wiping from front to back after urinating. Rationale:Besides taking all discharge medications as prescribed, including antibiotics, and notifying the primary health care provider if symptoms/signs of a UTI reappear, it is also important for the client to take adequate fluid amounts and use appropriate hygiene to prevent microorganisms from entering the bladder. Vaginal douches need to be avoided along with other products that can potentially irritate the perineal area. The client must be told to urinate at least every 4 to 6 hours.

The registered nurse (RN) reviews the results of the arterial blood gas (ABG) values with the licensed practical nurse (LPN) and tells the LPN that the client is experiencing respiratory acidosis. The LPN should expect to note which on the laboratory result report?

pH 7.25, Pco2 50 mm Hg Rationale:The normal pH is 7.35 to 7.45, and the normal Pco2 value is 35 mm Hg to 45 mm Hg (35 to 45 mm Hg). In respiratory acidosis, the pH is down, and the Pco2 is up. Therefore, the pH of 7.25 and the Pco2 of 50 mm Hg (50 mm Hg) option is the only one that reflects an acidotic condition. Options with an elevated pH (pH 7.50, Pco2 52 mm Hg pH 7.50, Pco2 30 mm Hg) indicate an alkalotic condition. (pH 7.35, Pco2 40 mm Hg) identifies normal values for pH and Pco2.

A client has been admitted to the hospital with a diagnosis of severe nausea and vomiting. The client has an indwelling intravenous (IV) catheter. The client's morning laboratory results show a serum blood sodium level of 130 mEq/L (130 mmol/L) and a serum blood chloride level of 92 mEq/L (92 mmol/L). Which intravenous fluids should provide free water, sodium, and chloride to the client? Select all that apply.

0.45% sodium chloride in water solution Dextrose 5% in 0.225% sodium chloride solution Rationale:The IV fluid 0.45% sodium chloride in water solution provides free water in addition to sodium and chloride, Dextrose 5% in 0.225% sodium chloride solution provides sodium, chloride, and free water. Lactated Ringer's solution is similar in composition to plasma except that it has excess chloride, no magnesium, and no bicarbonate. It does not provide free water or calories. The IV fluid 0.9% sodium chloride in water solution does not provide free water, calories, or other electrolytes. Dextrose 5% in lactated Ringer's solution is similar in composition to normal plasma except it does not contain magnesium. It does not provide free water.

The nurse is caring for a client with respiratory insufficiency. The arterial blood gas (ABG) results indicate a pH of 7.50 and a Pco2 of 30 mm Hg (30 mm Hg), and the nurse is told that the client is experiencing respiratory alkalosis. Which additional laboratory value should the nurse expect to note?

A potassium level of 3.0 mEq/L (3.0 mmol/L) Rationale:Signs/symptoms of respiratory alkalosis include tachypnea, change in mental status, dizziness, pallor around the mouth, spasms of the muscles of the hands, and hypokalemia. sodium level of 145 mEq/L (145 mmol/L), A magnesium level of 1.3 mEq/L (0.65 mmol/L), and A phosphorus level of 3.0 mg/dL (0.97 mmol/L) identify normal laboratory results.

The nurse is calculating a client's 24-hour fluid intake. The client consumed coffee (8 oz), water (8 oz), and orange juice (6 oz) for breakfast; soup (4 oz) and iced tea (8 oz) for lunch; and milk (10 oz), tea (8 oz), and water (8 oz) for dinner. The client also consumed 24 oz of water during the day. How many milliliters of fluid did the client consume in the 24-hour period? Fill in the blank.

2520 mL Rationale:The client consumed a total of 84 oz of fluid. Because 1 oz is equal to 30 mL, multiply 84 oz by 30 mL/oz. This yields 2520 mL.

The client is to receive a soapsuds enema. Which is the best position for administering an enema? Refer to figure.

A Rationale:The Sims, or left lateral position, is the position of choice for enema administration facilitating fluid to pass farther in the intestine. Many clients cannot tolerate the prone position. The lithotomy position is impractical for the procedure, and knee chest is too uncomfortable.

The nurse is caring for a group of clients. Which client is most likely to have a serum phosphorus level of 2.0 mg/dL (0.64 mmol/L)?

A client with a history of alcoholism Rationale:The normal serum phosphorus level is 3.0 to 4.5 mg/dL (0.97-1.45 mmol/L) so a value of 2.0 mg/dL (0.64 mmol/L) is indicative of hypophosphatemia. Causative factors include decreased nutritional intake and malnutrition. A poor nutritional state is associated with alcoholism. Hypoparathyroidism, chemotherapy, and vitamin D intoxication are causative factors of hyperphosphatemia.

The nurse is assisting in caring for a client who is receiving an intravenous infusion of 1000 mL of normal saline with 40 mEq of potassium chloride. The nurse is monitoring the client for signs of hyperkalemia. Which sign/symptom should be noted in the client if hyperkalemia is present?

Muscle weakness Rationale:Because potassium plays a major role in neuromuscular activity, elevation in serum potassium initially causes muscle weakness not muscle pain. Mental status changes and confusion are most likely noted in the client experiencing hypocalcemia hyponatremia. Depressed deep tendon reflexes are noted in the client with hypermagnesemia.

The nurse is reviewing the arterial blood gas results of the client. Blood gas results indicate a pH of 7.30 and a Pco2 of 50 mm Hg, and the nurse has determined that the client is experiencing respiratory acidosis. Which additional laboratory values should the nurse expect to note in this client?

Potassium 5.4 mEq/L Rationale:Serum potassium levels are often high in acidosis as the body attempts to maintain electroneutrality during buffering. In acidosis, extracellular hydrogen ion content increases, and hydrogen ions then begin to move into intracellular fluid. To keep the intracellular fluid electrically neutral, an equal number of potassium ions must leave the cell, creating a relative hyperkalemia. Sodium, magnesium, and phosphorus would remain within normal range.

The nurse is caring for a client with kidney failure. The nurse is told that the blood gas results indicate a pH of 7.30 and a HCO3- of 20 mm Hg, and that the client is experiencing metabolic acidosis. The nurse reviews the laboratory results and finds which value to be of concern?

Potassium level, 5.6 mEq/L Rationale:Signs/symptoms of metabolic acidosis include weakness, malaise, and headache. Hyperkalemia will occur because the cells will draw hydrogen into the cell and in exchange will push potassium out of the cell into the blood. The pH will be lower than 7.35, and the HCO3- ion level will be lower than 22 mEq/L. The remaining options identify normal laboratory values, whereas a potassium level of 5.6 mEq/L indicates hyperkalemia.

The nurse is reviewing the health care records of assigned clients. Which clients are at highest risk for excess fluid volume? Select all that apply.

The client with renal failure The client with chronic congestive heart failure (CHF) Rationale:Certain disease processes or medical treatments can put a client at risk for fluid volume excess. The causes of excess fluid volume include decreased kidney function, heart failure, cirrhosis, the use of hypotonic fluids to replace isotonic fluid losses, and the excessive ingestion of table salt. The clients with renal failure and CHF are at risk because the organs are impaired in regulating blood volume. The client with an ileostomy, the client on diuretics, and the client on GI suctioning are at risk for deficient fluid volume due to removal of fluids due to those specific medical treatments.

The nurse reviews electrolyte values and notes a sodium level of 130 mEq/L (130 mmol/L). The nurse expects that this sodium level would be noted in a client with which condition?

The client with the syndrome of inappropriate secretion of antidiuretic hormone Rationale:Hyponatremia is a serum sodium level less than 135 mEq/L (135 mmol/L). Hyponatremia can occur secondary to syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The client with an inadequate daily water intake, watery diarrhea, or diabetes insipidus is at risk for hypernatremia.

The nurse checks a client's skin turgor and documents that the client exhibits normal fluid balance. Which statement correctly describes what the nurse has documented?

The skin when pinched immediately fell back to normal when released. Rationale:Turgor (degree of elasticity) is checked by gently pinching up the skin over the abdomen, forearm, sternum, forehead, or thigh. In a person with normal fluid balance, the skin when pinched will immediately fall back to normal when released. If a fluid deficit is present, the skin may remain elevated or tented for several seconds after the pinch.

The nurse reviews a client's electrolyte results and notes a potassium level of 5.5 mEq/L (5.5 mmol/L). The nurse understands that a potassium value at this level would be noted with which condition?

Traumatic burn Rationale:A serum potassium level that exceeds 5.0 mEq/L (5.0 mmol/L) is indicative of hyperkalemia. Clients who experience the cellular shifting of potassium, as in the early stages of massive cell destruction (i.e., with trauma, burns, sepsis, or metabolic or respiratory acidosis), are at risk for hyperkalemia. The client with Cushing's syndrome or diarrhea and the client who has been overusing laxatives are at risk for hypokalemia.

Which electrocardiogram changes would the nurse note on the cardiac monitor with a client whose potassium (K+) level is 2.7 mEq/L (2.7 mmol/L)?

U waves Rationale:A serum potassium level less than 3.5 mEq/L (3.5 mmol/L) is indicative of hypokalemia. Potassium deficit is the most common electrolyte imbalance and is potentially life-threatening. Cardiac changes with hypokalemia may include peaked P waves, flattened T waves, depressed ST segment, and the presence of U waves.

The nurse is planning to reinforce dietary teaching about following a diet that is low in potassium to a client receiving a potassium-retaining (sparing) diuretic. The nurse should be sure to include which strategies to avoid foods high in potassium in the diet? Select all that apply.

Use eggs as a source for protein Avoid eating lunch meats and bolognas Eat salads with cabbage and lettuce and avoid spinach Rationale:Potassium is in most foods. Eggs are a protein source that is not as high in potassium as meats, especially organ and preserved meats such as lunch meats and bolognas. Most common salad ingredients such as lettuce, cabbage, carrots, celery, and onions are not rich in potassium. Spinach, however, is a good source of potassium. The client should avoid dried fruits, which are high in potassium. The client may eat bread and cereals that are not rich in potassium.

The nurse is caring for a client with a nasogastric tube in place for gastric decompression. The primary health care provider (PHCP) prescribes to have the tube irrigated once every 8 hours. Select the correct interventions the nurse should utilize in performing this procedure. Select all that apply.

Utilize 30 mL of 0.9% normal saline for the irrigating solution. After injecting the irrigating solution, pull back on the irrigation syringe. Rationale:A nasogastric tube is usually a Salem sump tube that is inserted through the nare with the end of the tube in the stomach. The tube is connected to low suction to remove gastric secretions and rest the bowel. Irrigation is done to maintain patency of the tube. Normal saline is used to limit loss of electrolytes. The usual amount is 30 mL injected through the tube, not the air vent, and then aspirated back into the syringe. The nurse should follow aseptic technique wearing clean gloves, not sterile technique. The client's serum electrolyte results do not need to be monitored since normal saline is the correct solution for irrigation.

A client undergoing renal dialysis is prescribed calcitriol to treat hypocalcemia. The nurse reinforces instructions and informs the client that this medication is also known as which nutrient?

Vitamin D Rationale:Calcitriol is a natural form of vitamin D and is an important regulator for calcium and phosphorus homeostasis. This vitamin improves calcium absorption from the intestine. Few foods are naturally rich in vitamin D except for oily fish such as salmon. Many foods are enriched with vitamin D such as milk. Vitamin D can be obtained by the body with exposure to sunlight.

The nurse is assisting in the care of a client who has a serum sodium level of 128 mEq/L (128 mmol/L). The nurse relates which of the client's signs and symptoms to this electrolyte imbalance? Select all that apply.

Weakness in all extremities Confusion with garbled speech Diarrhea with abdominal cramping Rationale:The normal serum sodium level for an adult is 135 to 145 mEq/L (135 to 145 mmol/L). Thus the client is experiencing low sodium, or hyponatremia, as evidenced by the weakness in extremities, confusion, and diarrhea with abdominal cramping. Signs of hyponatremia include rapid and thready pulse, postural blood pressure changes, weakness, abdominal cramping, poor skin turgor, muscle twitching and seizures, mental confusion, and apprehension. The neurological functioning of the client relates to the swollen brain cells that impair functioning. The gastrointestinal system is stimulated and hyperactive bowel sounds often occur. Dry skin and bleeding gums are not related to the low sodium level.

A client has the following laboratory values: pH of 7.55, HCO3- of 22 mm Hg, and a Pco2 of 30 mm Hg. Which action should the nurse take?

Encourage the client to slow down his breathing. Rationale:The client is in respiratory alkalosis based on the laboratory results of a high pH and low Pco2. Interventions for respiratory alkalosis are voluntary holding of the breath or slowed breathing and rebreathing exhaled CO2 by methods such as using a paper bag or rebreathing mask, as prescribed. Dialysis and administration of insulin are interventions for metabolic acidosis. Suctioning the client would improve respiration status and treat respiratory acidosis.

The nurse is monitoring a group of clients for acid-base imbalances. Which clients are at highest risk for metabolic acidosis? Select all that apply.

Client with pancreatitis Malnourished client Client with diabetes mellitus Client with status epilepticus Client with severe prolonged diarrhea Rationale:Clients who produce excessive acid, under produce bicarbonate, or overly eliminate bicarbonate develop metabolic acidosis. Clients with malnourishment, diabetes mellitus, and status epilepticus produce excessive acids leading to metabolic acidosis. Clients with pancreatitis under produce bicarbonate and develop metabolic acidosis. Clients with severe prolonged diarrhea develop metabolic acidosis due to the over elimination of bicarbonate. The client with asthma could develop an acid-base imbalance from a respiratory problem.

The licensed practical nurse (LPN) is assisting in the care of a client who overdosed on acetylsalicylic acid 24 hours ago. The LPN should report to the registered nurse (RN) which findings associated with an anticipated acid-base disturbance?

Drowsiness, headache, and tachypnea Rationale:The client who ingests a large amount of aspirin (acetylsalicylic acid) is at risk for developing metabolic acidosis 24 hours later. If metabolic acidosis occurs, the client is likely to exhibit drowsiness, headache, and tachypnea. In the very early hours following aspirin overdose, the client may exhibit respiratory alkalosis as a compensatory mechanism. By 24 hours after overdose, however, the compensatory mechanism fails and the client reverts to metabolic acidosis. The client with metabolic alkalosis (Decreased respiratory rate and depth and cardiac irregularities) is likely to experience cardiac irregularities and a compensatory decreased respiratory rate and depth. (Tachypnea, dizziness, and paresthesias) and (Disorientation, hypotension, and dyspnea) indicate respiratory acidosis and alkalosis, respectively

A client is determined to be in respiratory alkalosis by blood gas analysis. The nurse should monitor this client for signs of which electrolyte disorder that could accompany the acid-base imbalance?

Hypokalemia Rationale:Signs and symptoms of respiratory alkalosis include tachypnea, hyperpnea, weakness, paresthesias, tetany, dizziness, convulsions, coma, hypokalemia, and hypocalcemia. Remember that potassium, which is intracellular, and hydrogen ions exchange places to compensate and achieve an equilibrium with acid-base imbalances. The clinical picture does not include hypercalcemia, hypernatremia, or hypochloremia.

A client with a chronic airflow limitation is experiencing respiratory acidosis as a complication. The nurse trying to enhance the client's respiratory status should avoid performing which actions? Select all that apply.

Increase the liter flow to 5 L per nasal cannula Encouraging the client to breathe slowly and shallowly Rationale:The client with respiratory acidosis is experiencing elevated carbon dioxide levels because of insufficient ventilation. The nurse would encourage the client to breathe slowly and deeply (not shallowly) to expand alveoli and to promote better gas exchange. The nurse should increase the client's oxygen flow rate per nasal cannula to no more than 2 L, not 5L. Remember that the client with chronic pulmonary disease often does not respond to a high carbon dioxide level to breathe, but only low oxygen. If the nurse increases the oxygen too high, the client will have no stimulus to breathe. Elevating the head of the bed, monitoring the client's oxygen saturation level, and assisting the client to turn, cough, and deep breathe are helpful actions on the part of the nurse.term-36

A client with diabetes mellitus has a blood glucose level of 596 mg/dL on admission. The nurse anticipates that this client is at risk for which type of acid-base imbalance?

Metabolic acidosis Rationale:Diabetes mellitus can lead to metabolic acidosis. When the body does not have sufficient circulating insulin, the blood glucose level rises while the cells of the body use all available glucose and then break down glycogen and fat for fuel, which leads to the formation of ketones. The by-products of fat metabolism are acidotic, leading to the complication called diabetic ketoacidosis.

he nurse is assisting in the care of a client who had an ileostomy created a few days ago. The client has high output of drainage from the ileostomy. Based on this the nurse monitors the client for which acid-base imbalance?

Metabolic acidosis Rationale:Intestinal secretions are high in bicarbonate because of the effects of pancreatic secretions. These fluids may be lost from the body before they can be reabsorbed in conditions such as diarrhea or creation of an ileostomy. The decreased bicarbonate level creates the actual base deficit of metabolic acidosis. Clients with high intestinal output are not at risk for metabolic acidosis, or respiratory or metabolic alkalosis.

A client has had a set of arterial blood gases drawn. The results are pH, 7.34; Paco2, 37 mm Hg; Pao2, 79 mm Hg; and HCO3,- 19 mEq/L. The nurse interprets that the client is experiencing which acid-base imbalance?

Metabolic acidosis Rationale:Metabolic acidosis occurs when the pH falls below 7.35, and the bicarbonate level falls below 22 mEq/L. With respiratory acidosis, the pH drops below 7.35 and the carbon dioxide level rises above 45 mm Hg. With respiratory alkalosis, the pH rises above 7.45 and the carbon dioxide level falls below 35 mm Hg. With metabolic alkalosis, the pH rises above 7.45 and the bicarbonate level rises above 26 mEq/L.

An anxious client is experiencing respiratory alkalosis from hyperventilation as a result of anxiety. The nurse should do which action to help the client experiencing this acid-base disorder?

Provide emotional support and reassurance. Rationale:An anxious client benefits from emotional support and reassurance, which in turn reduces anxiety and may lower the respiratory rate. The client may benefit from the administration of a sedative or antianxiety medication, if it is prescribed. The client should try to breathe more slowly and shallowly. Lying supine provides no benefit to the client.

The nurse is assisting to admit a client with a diagnosis of acute Guillain-Barré syndrome. The nurse knows that if the disease progresses to a severe level, the client will be at risk for which acid-base imbalance?

Respiratory acidosis Rationale:Guillain-Barré is a neuromuscular disorder in which the client may experience weakening or paralysis of the muscles used for respiration. This could cause the client to retain carbon dioxide, which leads to respiratory acidosis resulting from progressive respiratory insufficiency as the paralysis ensues.

The nurse is caring for a client who is nervous and is hyperventilating. The nurse should monitor the client for signs of which acid-base imbalance?

Respiratory alkalosis Rationale:A client who hyperventilates blows off excessive carbon dioxide. This would have the effect of inducing alkalosis. Because a respiratory problem is triggering the alteration, it is called respiratory alkalosis. The client is not at risk for metabolic acidosis or alkalosis or respiratory acidosis from hyperventilating.

A client has been diagnosed with metabolic alkalosis. Which laboratory values are most important for the nurse to monitor for this client? Select all that apply.

Serum electrolytes Arterial blood gases (ABGs) Rationale:Metabolic alkalosis occurs when the arterial blood pH is greater than 7.45, and the HCO3- is greater than 26 mEq/L. Thus, to monitor this, a client's ABGs, which measure the pH, CO2, and HCO3- in arterial blood, need to be monitored. The client with metabolic acid-base imbalances are prone to alterations in potassium so the serum electrolytes should be monitored. The client with metabolic alkalosis is initially prone to hypokalemia. Although the disorder that may be causing the metabolic alkalosis may also affect the other laboratory values, the CBC, which includes the red blood cell count, and the serum bilirubin, are not the most important values to monitor for a client in metabolic alkalosis.

Which arterial blood gas (ABG) result should the nurse anticipate in the client who develops metabolic alkalosis after profuse vomiting for 2 days?

pH 7.49; Pco2 45; HCO3- 30 Rationale:Vomiting results in a loss of hydrogen ions from the gastrointestinal tract, which leads to an increase in serum bicarbonate. Metabolic alkalosis occurs with an excess in serum bicarbonate. In metabolic alkalosis the pH rises as does the bicarbonate. A pH 7.32; Pco2 35; HCO3- 20 indicates metabolic acidosis, pH 7.30; Pco2 50; HCO3- 24 indicates respiratory acidosis, and pH 7.52; Pco2 30; HCO3- 20 indicates respiratory alkalosis.

Which of these clients are most likely to develop fluid (circulatory) overload? Select all that apply.

premature infant A 101-year-old man A client with heart failure A client receiving renal dialysis Rationale:Clients with cardiac, respiratory, renal, or liver diseases and older and very young clients cannot tolerate an excessive fluid volume. The risk of fluid (circulatory) overload exists with these clients.